Provider Demographics
NPI:1619518743
Name:GRAYHAM, KYLE ALTON
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ALTON
Last Name:GRAYHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 MAY APPLE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-5799
Mailing Address - Country:US
Mailing Address - Phone:870-321-5339
Mailing Address - Fax:
Practice Address - Street 1:3001 MAY APPLE DR
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-5799
Practice Address - Country:US
Practice Address - Phone:870-321-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1234563747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider